Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elderwood At Wheatfield during CMS and state inspections, most recent first.
The facility failed to maintain sufficient nursing staff, leading to unmet resident needs and care plan deviations. Staffing levels fell short on multiple occasions, impacting residents' ability to receive timely care, such as getting out of bed, receiving showers, and having call lights answered. Staff interviews confirmed awareness of the shortages, and residents reported delays and neglect due to insufficient staffing. The Director of Nursing and other staff acknowledged the challenges and the need for more staff to provide adequate care.
The facility failed to maintain an effective pest control program, leading to a significant presence of flies in Unit 1. Observations showed flies in resident rooms, dining areas, and common areas, with residents and staff expressing concerns about unsanitary conditions. The facility lacked a pest control policy, and maintenance staff were unaware of the issue, indicating a breakdown in communication and response.
A hospice nursing assessment for a resident with severe cognitive impairment was conducted in the dining room while the resident was being assisted with lunch, compromising their privacy and dignity. The assessment took place in the presence of other residents, contrary to the facility's policy on maintaining resident dignity and privacy. Staff interviews confirmed that such assessments should occur in private settings, like the resident's room.
The facility failed to honor residents' care preferences, particularly regarding bathing schedules, due to staffing issues. A resident did not receive showers twice a week as preferred, with inconsistent care plans and schedules. Two other residents also did not receive showers as scheduled, with staff citing short staffing as the reason. The DON and Acting Unit Manager were unaware of these failures.
The facility failed to maintain a sanitary environment in Unit 1, where a strong urine odor was consistently present. Observations and interviews revealed the odor in specific resident rooms, indicating inadequate housekeeping services. Staff and residents acknowledged the issue, with challenges in maintaining cleanliness due to staffing shortages in housekeeping.
A resident with a history of stroke and hemiplegia reported being forcibly yanked out of bed by a nurse, causing discomfort. The incident was reported internally on the evening of May 31st, but the official report to the Department of Health was delayed until June 1st, exceeding the two-hour reporting requirement. The Director of Nursing acknowledged the delay, citing a need to gather more facts, which led to a deficiency in timely reporting.
A resident at high risk for skin integrity issues developed a pressure ulcer on the right buttock, which was not promptly assessed or documented by the LTC facility staff. Despite the facility's policy, there was a delay in notifying the appropriate nursing staff, leading to a lack of timely treatment and monitoring. The issue was attributed to miscommunication, resulting in a deficiency finding during the survey.
A resident with severe cognitive impairment and dementia was found in the parking lot after leaving the facility undetected in their wheelchair. Despite a history of wandering, the resident was assessed as having no elopement risk on the day of the incident. The receptionist was unaware of the resident's restrictions, leading to a lack of supervision and communication about the resident's elopement risk.
A resident with Alzheimer's and severe cognitive impairment was not provided with the necessary adaptive eating equipment as per their care plan, leading to food spillage and lack of assistance during meals. Staff interviews revealed a lack of adherence to the care plan, with the kitchen and nursing staff failing to ensure the correct utensils were provided, despite the importance of such equipment for the resident's independence and safety.
The facility failed to maintain an effective infection prevention and control program, as CNAs did not adhere to enhanced barrier precautions and proper hand hygiene during care for residents with multidrug-resistant infections and incontinence. Despite clear signage and facility policies, CNAs did not wear appropriate PPE or change gloves and wash hands as required, leading to potential cross-contamination risks.
The facility did not update the DOH Staffing Report with actual staffing numbers per shift, as required. Observations and interviews revealed that the report was not updated daily, and staff were unaware of its purpose. The facility lacked a policy for completing the report.
The facility failed to maintain complete medical records for three residents regarding the 2023 influenza vaccine. A resident received the vaccine without a scanned consent form, another cognitively impaired resident also lacked a scanned consent, and a third resident who declined the vaccine had no scanned declination form. Staff interviews revealed inconsistencies in the process of scanning these forms into the electronic medical record.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents, as evidenced by not meeting the established minimum staffing levels on multiple occasions. The facility's staffing plan required a specific number of nurses and certified nurse aides for each shift, but records showed that these levels were not met on several dates. Interviews with staff, including the Scheduling Specialist and the Director of Nursing, confirmed awareness of the staffing shortages and the challenges faced in providing adequate care. The Director of Nursing acknowledged that nurses were expected to assist with resident care when staffing was low, but it was unclear if this was consistently happening. Residents and their families reported numerous issues related to the staffing shortages, including delays in getting out of bed, missed showers, and long wait times for assistance. Resident Council minutes and interviews with residents highlighted concerns about late get-ups and unmet care needs. Residents expressed frustration with having to wait for assistance, and some reported that staff would turn off call lights without returning to provide help. Family members and the Ombudsman also noted the impact of insufficient staffing on resident care, describing it as neglect due to the lack of available staff. Observations and interviews with staff further illustrated the challenges posed by inadequate staffing. Certified Nurse Aides reported being unable to complete all required tasks, such as providing showers and timely incontinent care, due to the high number of residents assigned to them. Some staff members expressed feeling overwhelmed and exhausted, with one aide noting that staffing was at its worst in their 33 years at the facility. The Acting Unit Manager and other nursing staff acknowledged the need for more staff to provide adequate care, particularly given the high acuity of residents on certain units.
Pest Control Deficiency in Resident Unit
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant presence of flies in one of the resident units, specifically Unit 1. Observations revealed flies in resident rooms, dining areas, and common areas, with residents and staff expressing concerns about the unsanitary conditions. The facility was unable to provide a policy and procedure for pest control, and there were no fly lights on the resident units, despite service reports indicating they had been serviced. Multiple observations and interviews highlighted the presence of flies landing on residents, their food, and in areas with strong urine odors. Residents reported the issue to staff, but there was no evidence of effective action taken to address the problem. Maintenance staff were unaware of any current fly issues, and no work orders related to flies had been submitted since the end of July, despite ongoing complaints from residents and their families. Interviews with various staff members, including nurses, maintenance, and housekeeping, revealed a lack of communication and awareness regarding the fly problem. The Director of Facility Management and the Administrator were also unaware of the current fly concerns, indicating a breakdown in the reporting and response process. The deficiency was linked to gaps around air conditioning units, which were not properly sealed, allowing flies to enter the facility.
Resident Dignity Compromised During Hospice Assessment
Penalty
Summary
The facility failed to ensure that each resident was treated with respect and dignity, specifically in the case of Resident #59, who was on hospice care. During a standard survey, it was observed that a hospice nursing assessment was conducted in the dining room while Resident #59 was being assisted with their lunch. This assessment was performed in the presence of other residents, compromising the resident's privacy and dignity. The facility's policy on Resident's Rights emphasizes the importance of respecting each resident's dignity and privacy, which was not adhered to in this instance. Resident #59 had severe cognitive impairment and was on hospice care due to a terminal diagnosis. The hospice nurse conducted a physical assessment in the dining room, which included listening to the resident's heart and lungs and assessing their limbs, while other residents were nearby. Interviews with staff, including the hospice nurse and the Director of Nursing, confirmed that the assessment should have been conducted in a private setting, such as the resident's room, to maintain dignity and privacy. The Director of Nursing acknowledged that the dining room was not an appropriate location for such assessments unless specifically requested by the resident.
Failure to Honor Resident Care Preferences Due to Staffing Issues
Penalty
Summary
The facility failed to honor the residents' rights to self-determination and choice in their care, specifically regarding bathing preferences and schedules. Resident #1, who is cognitively intact and has a preference for showers twice a week, did not receive showers as scheduled due to staffing issues. The care plan and shower schedule were inconsistent, and there was no documented evidence of showers being provided. Interviews with staff and the resident's health care agent confirmed the lack of adherence to the resident's preferences, with staff citing short staffing as the reason for not providing the showers. Resident #56, who requires substantial assistance and is cognitively intact, also did not receive showers twice a week as preferred. The resident expressed dissatisfaction with not being able to get out of bed at their preferred time and not receiving showers as scheduled. Staff interviews revealed that the unit was often understaffed, preventing them from meeting the resident's preferences for bathing and getting out of bed. The Acting Unit Manager and Director of Nursing were unaware of the failure to meet the resident's preferences. Resident #55, who has severe cognitive impairment and requires total assistance, did not receive showers twice a week as per their care plan. The resident's family member reported that it had been three weeks since the last shower. Staff interviews indicated that the unit was frequently understaffed, leading to the inability to provide showers as scheduled. The Director of Nursing was not aware of the failure to meet the resident's bathing preferences, and the Acting Unit Manager acknowledged the need for more help to meet the residents' needs.
Persistent Urine Odor in Resident Unit Due to Inadequate Housekeeping
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment in one of its resident units, specifically Unit 1, where a strong urine odor was consistently present throughout the survey period. Observations on multiple occasions revealed the persistent odor in the unit and specific resident rooms, indicating inadequate housekeeping services. The facility's policy on maintaining clean and hygienic resident rooms was not effectively implemented, as evidenced by the strong urine smell that was noted during various observations and interviews. Interviews with staff and residents highlighted the issue, with a resident expressing that they had become accustomed to the odor, and a family member confirming the unpleasant smell. Staff members, including a Licensed Practical Nurse, a Registered Nurse Unit Manager, and a Certified Nursing Assistant, acknowledged the presence of the odor and the challenges in maintaining cleanliness due to staffing shortages in housekeeping. The Environmental Services Supervisor and the Administrator also recognized the issue, with the Supervisor noting the difficulty in cleaning every floor daily and the Administrator expecting immediate notification to housekeeping when odors were detected.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident within the required timeframe to the New York State Department of Health. The incident involved a resident with a history of stroke, hemiplegia, hemiparesis, repeated falls, and aphasia, who was reportedly mishandled by a nurse. The resident alleged that the nurse forcibly yanked them out of bed and into a wheelchair against their will, causing discomfort. This incident was reported internally by a Registered Nurse to the Director of Nursing and the Administrator via email on the evening of May 31st, but the official report to the Department of Health was not submitted until June 1st, exceeding the two-hour reporting requirement. Interviews conducted during the investigation revealed that the Director of Nursing acknowledged receiving the initial report on May 31st but delayed reporting to gather more facts. The Director of Nursing admitted that the report should have been submitted earlier, in compliance with the regulation requiring immediate reporting within two hours. The Administrator confirmed the expectation for timely reporting of abuse allegations, as per regulatory requirements. This delay in reporting constitutes a deficiency in the facility's adherence to mandated reporting protocols.
Delay in Pressure Ulcer Assessment and Treatment
Penalty
Summary
The facility failed to ensure timely assessment and treatment of a pressure ulcer for Resident #38, who was at high risk for skin integrity issues due to multiple factors including chronic kidney disease, incontinence, and a history of pressure ulcers. Despite the facility's policy requiring immediate assessment and documentation of new skin conditions, there was a delay in evaluating a newly identified pressure ulcer on the resident's right buttock. The resident reported irritation and pain in the area, and although Certified Nursing Assistant #4 observed the open area and applied ointment, they did not ensure that a licensed nurse was notified for further assessment. Subsequent observations by other staff members, including Certified Nursing Assistant #18, confirmed the presence of the open area, yet there was no documented evidence of assessment or monitoring in the resident's medical record from 8/8/24 to 8/12/24. Interviews revealed that the nursing staff, including Licensed Practical Nurse #5, were not informed of the skin issue, resulting in a lack of appropriate wound care and monitoring. The Acting Unit Manager/Assistant Director of Nursing eventually assessed the wound on 8/13/24, identifying it as a Stage II pressure ulcer, but acknowledged that they had not been notified earlier, which could have prevented the delay in treatment. The facility's Director of Nursing and Administrator were unaware of the issue until it was brought to their attention during the survey. The Administrator attributed the oversight to miscommunication rather than a lack of assessment, despite the facility's policy clearly outlining the steps for reporting and assessing new skin conditions. The delay in notification and assessment was recognized as a deficiency, as it potentially increased the risk of the ulcer worsening or becoming infected.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for a resident with severe cognitive impairment and a history of dementia, cognitive communication deficit, and anxiety disorder. On 8/9/23, the resident was found in the parking lot by a visitor after having left the facility undetected in their wheelchair. The resident's Minimum Data Set dated 6/13/23 documented severe cognitive impairment with no wandering behaviors, and their care plan included interventions for wheelchair mobility requiring extensive assistance. However, a progress note from 7/25/23 indicated the resident was wandering the hallways, suggesting a change in behavior that was not adequately addressed. The facility's policy on elopement required assessments to determine the risk of unsafe wandering, but the resident was assessed as having no risk for elopement on the day of the incident. The receptionist on duty did not realize the resident had moved from the patio to the parking lot until alerted by a visitor. Interviews revealed that the receptionist was unaware the resident was not allowed outside alone and that there was a lack of communication regarding the resident's elopement risk. The incident highlighted a failure in supervision and risk assessment, as the resident was outside unsupervised for 15 to 20 minutes before being brought back inside.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide special eating equipment and utensils for Resident #85, who required them as per their care plan. Resident #85, diagnosed with Alzheimer's disease and severe cognitive impairment, needed supervision and assistance during meals. The care plan specified the use of bowls for solid foods and mugs for beverages to aid in self-feeding and prevent spills. However, during multiple observations, Resident #85 was served meals on plates and beverages in cups, contrary to the care plan, and without staff assistance, leading to food being pushed off the plate. Interviews with staff, including Certified Nurse Aides and the Food Service Director, revealed a lack of awareness and adherence to the care plan. The Certified Nurse Aides acknowledged the importance of using the correct adaptive equipment to prevent spills and potential burns but failed to ensure that Resident #85 received the appropriate utensils. The Food Service Director admitted that it was the kitchen's responsibility to ensure the correct equipment was on trays before leaving the kitchen, but they were unaware of the oversight. Further interviews with the Director of Rehabilitation and the Registered Dietician highlighted the significance of adaptive equipment in promoting independence and nutritional intake for residents like Resident #85. The Director of Nursing emphasized the expectation for staff to review meal slips to ensure residents' safety and proper equipment use. Despite these expectations, the facility did not comply with the care plan, resulting in the deficiency noted during the survey.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of Certified Nurse Aides (CNAs) #4, #18, and #5. Specifically, CNAs #4 and #18 did not adhere to enhanced barrier precautions while providing care to a resident with a multidrug-resistant organism infection. This resident, who had a suprapubic urinary catheter, required substantial assistance for toileting and was on enhanced barrier precautions. Despite the presence of a sign indicating the need for gowns, gloves, and masks, the CNAs did not wear the appropriate personal protective equipment during direct care activities, such as emptying the catheter bag and transferring the resident to a shower chair. In another instance, CNA #5 did not follow proper hand hygiene protocols during incontinent care for a resident who was always incontinent of urine and required maximal assistance for toileting. CNA #5 failed to change gloves or wash hands after removing a wet incontinence brief and before continuing with the cleaning process. This lapse in hand hygiene occurred despite the facility's policy requiring frequent handwashing, especially after handling soiled objects. Interviews with the involved CNAs and facility staff, including the Nurse Educator, Director of Nursing, and Regional Registered Nurse Infection Preventionist, revealed a lack of adherence to infection control protocols. The staff acknowledged the need for protective equipment and proper hand hygiene to prevent cross-contamination and contamination of residents. However, the facility had not completed in-service training for all employees on enhanced barrier precautions, contributing to the observed deficiencies.
Failure to Update Daily Staffing Information
Penalty
Summary
The facility failed to post daily updated staffing information, as required, for licensed and unlicensed nursing staff responsible for resident care per shift. Observations from August 8 to August 14 revealed that the Department of Health (DOH) Staffing Report, posted at the front desk, did not reflect the actual number of staff for each shift. A review of the past 30 days of staffing reports showed they were not updated with the actual staffing numbers per shift. Interviews with facility staff, including the Scheduling Specialist, Director of Nursing, and Administrator, revealed a lack of understanding and training regarding the purpose and requirements of the DOH Staffing Report. The Scheduling Specialist admitted to not updating the report with actual staffing numbers and was unaware of its purpose. The Director of Nursing and Administrator also misunderstood the requirement, believing the report did not need to be updated per shift. Additionally, the facility did not have a policy in place for completing the DOH Staffing Report.
Incomplete Documentation of Influenza Vaccine Consents and Declinations
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for residents in accordance with accepted professional standards. Specifically, three residents had issues with missing documented evidence of signed consents or declinations for the 2023 influenza vaccine. Resident #1, who was cognitively intact, received the influenza vaccine, but there was no scanned copy of the signed consent form in the electronic medical record. Resident #12, who was cognitively impaired, also received the vaccine, but similarly, there was no scanned consent form. Resident #59, who was severely cognitively impaired, declined the vaccine, yet there was no scanned copy of the signed declination form. Interviews with facility staff revealed that the process for handling consent and declination forms was not consistently followed. The Assistant Director of Nursing and the Director of Nursing both stated that consents or declinations should be scanned into the electronic medical record by unit clerks after the vaccine was administered. However, the Unit Clerk admitted to being unable to locate the signed forms in the paper medical records. The Administrator expected accurate documentation of immunizations and proper scanning of consents or declinations, but this was not achieved, leading to incomplete medical records for the residents involved.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 157 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Niagara Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| North Gate Health Care Facility | 2.5 mi | ★★★★★ | 1 | 0 |
| Degraff Memorial Hospital-skilled Nursing Facility | 5.1 mi | ★★★★★ | 1 | 0 |
| Elderwood At Grand Island | 5.2 mi | ★★★★★ | 1 | 0 |
| Schoellkopf Health Center | 7.3 mi | ★★★★★ | 13 | 0 |
| Schofield Residence | 7.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Elderwood At Wheatfield.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.